Exam One portion of exam Flashcards by Glen McCormick

________________ are the gold standard of medications, must be proven to have the same therapeutic effect on the body no matter who makes it.

preferred agents

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_________ is the study of what the body does to the drug when administered

pharmacokinetics

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pharmacokinetics

is the study of what the body does to the drug when administered

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the extent of absorption

bioavailability

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bioavailability

the extent of absorption

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typically less than 100% bioavailability

oral medications

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oral medications typically have ________ bioavailability

less than 100%

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IV medications typically have _____ bioavailability

100%

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typically have 100% bioavailability

IV medications

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______ – the extent of absorption ( is higher with an IV for example, is typically 100%)

bioavailability

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______ – time for drug to actually illicit therapeutic response from administration

time to onset

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______ – time for drug to reach its maximum therapeutic response

time to peak effect

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_____ –the maximum concentration of the drug in the body after administration

peak level

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______ – length of time the concentration of the drug in the blood or tissues is sufficient to actually illicit a response

duration of action

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Movement of a drug from its site of administration into the bloodstream for distribution to the tissues

absorption

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Refers to the transport of a drug by the bloodstream to its intended site of action

distribution

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if there is good blood supply there will be ______distribution

rapid

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Most often occurs in the liver, but can happen in the skeletal muscle, kidneys, lungs, plasma and intestinal mucosa.

metabolism

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______ – phenomenon where drug is metabolized in a certain part of the body and it is reduced by the time that it gets to the intended target site

first pass effect

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________ is the fraction or %U of a drug that reaches systemic circulation, IV are 100 % ______

bioavailability

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primary organ of excretion?

kidney
(the bowels also excrete, but not as much)

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Time required for one-half of a given drug to be removed from the body

half life

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the interactions between the medicine and target cells, body systems, and organs to produce effects

pharmacodynamics

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–through drug receptor interaction, so what happens is a drug molecule joins a reactive site on a cell to produce a response

receptor interactions

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– enzymes are substances that break down almost every biochemical reaction in a cell, drugs can produce effects by interreacting with these enzyme systems by either inhibiting or enhancing the enzyme.

enzyme interactions

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– actually interact with the cell membranes or cellular processes, drugs either physically or structurally interfere cellular processes. example is a cancer drug (pretty harsh)

nonselective interactions

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two solutions mixed together than are ______, when they are mixed they create a precipitate which can cause an embolism, as well as the drugs not working properly

incompatible

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–goes over the hospital to hold the standard of care where it needs to be.

the Joint commission (Medicare does this too)

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– develop standards for nurses, do policy statements and resolutions

ANA

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– promoting patients informed decision making, supporting their informed decision

autonomy

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– doing or actively promoting good, whatever you do is to best help the patient

beneficence

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– respecting privileged information, known when to include or not include family

confidentiality

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– being fair and ethical in your actions

justice

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– avoiding doing deliberate harm

nonmaleficence

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– duty to tell the truth, informed consent

veracity

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Complete all forms including incident report according to facility policy and procedure
Factual information only
Avoid judgmental words
Document changes in patient’s physical or mental status
Document that physician was notified (who, time, follow-up actions/orders)
Ongoing patient monitoring

reporting/documenting med error

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Younger than 38 weeks of gestation is a ?

premature

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Younger than 1 month?

neonate

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1 month up to 1 year

infant

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1 year up to 12 years

child

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Immature Organs
Especially Liver and Kidneys  excretion impaired
Limited medication-metabolizing capacity
Sensitivity of receptor sites vary with age
Skin is thinner

neonatal and pediatric patients characteristics that affect dosage

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Rapidly developing tissues may be more sensitive to drugs
Stomach acid (pH) is less acidic  decreased ability to kill bacteria
Lungs have weaker mucous barriers
Body temp is less well regulated and dehydration occurs easily
less stomach acid
peristalsis is slower

neonatal and pediatric patients characteristics that affect dosage

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What trimester is the highest risk for adverse effects to happen to the fetus?

1st trimester

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Functioning of Organ Systems Declines
Drug Sensitivity is Altered
General Decrease in Body Weight
Malnutrition
Changes in Drug Molecule Receptors
Important to Monitor Liver and Kidney Function Via Labs

age considerations for elderly

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1 gram

1000 mg

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1 mg

1000 mcg

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1 L

1000 mL

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3 teaspoons (tsp)

1 Tablespoon (T)

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1 cc

1 mL

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1 teaspoon (tsp)

5 mL

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1 table spoon (T) = ____ mL

15 mL

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1 kg

2.2 lbs

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1 oz

30 mL

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1 in

2.54 cm

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tachycardia
tinnitus
hearing loss
dimness of vision
headache
dizziness
n/v
diarrhea
sweating thirst
hyperventilation hypoglycemia

s/s chronic salicylate toxicity

most common in adults: tinnitus (first sign) and hearing loss

most common in children: drossiness, hyperventilation, hypoglycemia

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Strong abuse potential
Sedation, dizziness, lightheadedness, drowsiness
Itching or pruritus, rash and hemodynamic changes
Respiratory depression – most severe adverse effect
GI tract adverse effects
Urinary retention
Severe hypersensitivity or anaphylactic reaction
Cough suppression
orthostatic hypotension
itching (histamine release)

adverse effects of opioids

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Monitor vitals and auscultate lungs for congestion
For respiratory rates < 12, withhold drug and stimulate breathing
Administer an _____ antagonist (Narcan) to restore respiratory rate
Fall precautions (orthostatic hypotension)
Monitor bowel function, encourage fiber supplements, stool softeners
For vomiting, administration of antiemetic, ensure adequate hydration
Monitor I&O, watch for urinary retention, bladder distention
Encourage patients to urinate every 4 hours (perception of need decreases)
Prepare to insert catheter as needed to empty bladder
Encourage to cough frequently to prevent buildup of respiratory secretions (especially postop)
Recommend lowest possible dose and short term only

interventions for opioids

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Measure baseline vitals and monitor throughout therapy
Administer orally, IM, IV, SC, rectally, epidurally
Swallow without crushing or chewing if sustained release
Administer IV opioids by diluting as recommended and slowly; have naloxone and resuscitation equipment available
Monitor PCA and pump setting carefully
Administer to cancer patients on a fixed around the clock schedule rather then PRN

opioids administration

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don’t drive heavy machinery when first starting _____
sit down if you get light headed
drink lots of water,
move around (prevents constipation and pneumonia)
rise slowly from a reclining or sitting position
report any problems with urination
cough and breath deep regularly (pneumonia prevention)
nausea vomiting problems – take with food first, if it persists use an antiemetic
take the opioids as prescribed

opioids patient instructions

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Known allergy
Severe Asthma
Pregnancy Risk Category D
Renal failure
Increased intracranial pressure
Biliary colic or biliary tract surgery
Preterm labor

contraindications for opioids

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Can be used transdermally (for long term)
Strong opioid analgesic
Rapid onset/Short duration when injected
Caution! Disposal of Patches
Binds with opioid receptors in brain and spinal cord to inhibit pain transmission (acts like a closed gate to block pain transmission)

fentanyl

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For Severe Pain
Schedule II
Mainly used - oral and parenteral routes
“Non-ceiling” drug

morphine

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More effective than most opioids given orally
Larger doses for analgesia than antitussive
Metabolized to morphine
not as strong as morihine, but has fewer side effects

codeine

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Similar to codeine in analgesic and antitussive effects
Schedule II
Metabolized to hydromorphone
metabolizes to hydromorophine, is given with Tylenol or ibuprophen

hydrocodone

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Schedule II
Synthetic
Action similar to morphine, more frequent administration
Normeperidine
Use has greatly declined
Drug Interactions
can cause less smooth muscle spasm, so less biliary and renal cholic with this drug

meperidine

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normeperidine –is toxic and can accumulate with chronic use or large doses, or with someone in renal failure who is taking ______
this is nonreversable, there is not a reversal drug that you can give

contraindicated in anyone who is taking amphetamines or MAOI in the last three weeks because it can lead to serotonin syndrome
serotonin syndrome leads to high fever, seizures, and death

meperidine

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Can occur after only 2 weeks of opioid use
Gradual dosage reduction minimizes risk
S&S if someone is in withdrawal: they may be drug seeking, their eyes can be dilated (madriasis), piloerection (hair is standing up on body), very diaphoretic (really sweaty, cold, clammy), rhinorrhea (runny nose), lacrimation (overproduction of tears), vomiting and diarrhea, CO insomnia, elevated bp and pulse, CO muscle cramps, CO arthralgia (pain in joint), super anxious, physically painful to some people

opioid withdrawl

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Schedule IV controlled substance
History of substance abuse
Head injury, increased intracranial pressure
Decreased respiratory reserve
Hepatic or renal disease

Agonist-Antagonists - Precautions

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Reversal of opioid effects, overdose
Reversal of neonatal respiratory depression due to maternal analgesia
Most reverse respiratory depression, some will reverse constipation and euphoria; overdose

Opioid Antagonist - Indications

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Blocks opioid receptors
Binds to a pain receptor but does not reduce pain signals.
Competes with and reverses the effects of agonist and agonist-antagonist drugs at the receptor sites

Opioid Antagonist – Pharmacologic Action

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IV, IM, subQ, Intranasal
Remember the half-life of ______ is much shorter than that of opioids so may have to give more________; monitor!!!
Will produce withdrawal symptoms when given to opioid dependent people

can cause seizures, other withdrawal symptoms when given to opioid dependent people

expect upset person when narcaned if they just came out of surgery

KNOW THE DOSAGES FOR EMERGENT DRUGS, NARCAN IS AN EMERGENT DRUG

Opioid Antagonist Prototype = Narcan (naloxone)

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Increase respiratory rate, increase heart rate, increase blood pressure
Abstinence syndrome (withdrawal) – hypertension, vomiting, tremors

can cause abstinence syndrome or withdrawal, hypertension, bomiting, tremors. SEIZURES,

can bag, intubate, etc. if appropriate

Opioid Antagonist – Adverse Effects

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Monitor vital signs (watch for increase in blood pressure)
Monitor for tachycardia
Have oxygen and resuscitation equipment ready
Expect adverse effects in an opioid dependent patient

have oxygen and resuscitation equipment ready

Opioid Antagonists - Interventions

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IM, SC, IV, Intranasal
Titrate doses carefully
Monitor vital signs every 5-15 minutes for several hours
Effects last 60-90 minutes, can need another dose
Be aware that the drug may increase pain by reducing opioid effects and precipitate acute withdrawal for a dependent patient

Opioid Antagonists - Administration

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if theyre awake, tell them that you might have to administer it again (even if theyre not awake),

warm patients that they will have pain because it reverses

stimulate before you give ______, but don’t spend a lot of time doing it

Opioid Antagonists – Patient Instructions

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Opioid dependence
Respiratory depression due to nonopioid drugs

Opioid Antagonists - Contraindications

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Cardiac irritability
Head injury, increased intracranial pressure
Brain tumor
Seizure disorders

Opioid Antagonists - Precautions

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Coadministration of opioids

alcohol, antihistamines, barbiturates, benzodiazepines, phenothiazine, other CNS depressants

Respiratory Depression

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Opioids
+
Monoamine Oxidase Inhibitors

Respiratory Depression, Seizures, Hypotension

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Abnormal increase in serum levels of amylase, alanine aminotransferase, alkaline phosphatase, bilirubin, lipase, creatinine kinase, and lactate dehydrogenase
Abnormal decrease in urinary 17-ketosteroid levels
Increase in urinary alkaloid and glucose concentrations

Lab Test Interactions [for opioids ?]

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Stimulation
Ventilatory assistance
Opioid Antagonists

Treatment of Overdose? Or Respiratory Depression

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Analgesic, Antiinflammatory and Antipyretic Activity
Also for headaches, myalgia, neuralgia, arthralgia, postoperative pain
Relief of pain with rheumatoid arthritis, juvenile arthritis, ankylosing spondylitis, osteoarthritis, gout, hyperuricemia

NSAIDS - Indications

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they inhibit prostaglandin synthesis in the CNS and the periphery

NSAIDS

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_____ only inhibits in the CNS, NOT the PERIPHERY

ACETAMINOPHEN

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What are the NSAIDS?

Aspirin
Ibuprofen (Advil, Motrin)
Naproxen (Naprosyn, Alleve)
Indomethacin (Indocin)
Ketorolac (Toradol)

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Inhibit cyclooxgenase (COX)
Two forms of this enzyme =
COX – 1 and COX - 2

NSAIDS – Expected Pharmocologic Actions

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______ stimulate release of protective prostaglandins in order to maintain homeostasis in the body
protect gastric mucosa
enhance platelet aggregation
promotes kidney function

COX 1 enzymes

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_______stimulates release of prostaglandins in response to injury
inflammation
pain
fever

COX 2

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GI tract
Heartburn to GI Bleeding
Acute Renal Failure (especially if dehydrated)
Due to disruption of prostaglandin function
______ block protective effects of COX-1 on the kidneys
Reye’s Syndrome
Salicylism

NSAIDS - Adverse Effects

Monitor for signs of bleeding
Test for and treat Helicobacter pylori infection
Recommend a proton pump inhibitor during NSAID therapy
Monitor I & O, BUN and Creatinine
Monitor for salicylism
With long term use of non-aspirin NSAIDS: Monitor for signs of embolic event
Recommend low dose aspirin to prevent embolic events

NSAIDS -Interventions

Make sure patients swallow enteric coated or sustained release whole
Due to increased bleeding tendencies, discontinue aspirin one week before scheduled surgery
Monitor for initial and continued therapeutic effects
Prophylactic use of aspirin to inhibit platelet aggregation is usually 81mg/day

Administration of NSAIDS

take with food

report gastric irritation

report unusual or prolonged bleeding

report changes in urine output or retention

report edema, bloating, weight gain

don’t give aspirin to kids under 18 who have viral symptoms

report chest pain, shortness of breath, stroke symptoms

report sign of overdose salicylism
first sign is tinnitus

NSAIDS – Patient Instructions

Known drug allergy
Documented Aspirin Allergy should have NO NSAIDS
Risk for bleeding
Vitamin K deficiency
Peptic ulcer disease
Risk for epistaxis
Severe Renal or Hepatic Disease
Chronic Alcohol Abusers
Children and Adolescents with viral infections (Reye’s)
Pregnancy
1 week prior to surgery

NSAIDS - Contraindications

Blocks pain centrally and peripherally
Decrease responsiveness to pyrogens
Anti-platelet activity (bleeding risk)
Toxicity above 300 mcg/mL
Pain that is low to moderate
Gastric upset

Aspirin

______ is a salicylate, it blocks pain centrally and peripherally, decreases responsiveness to pyrogens (substances that cause fever) by acting on the hypothalamus, prevents prostaglandin from increasing inflammation, also have an antiplatelet activity (bleeding risk) cetyle portion of aspirin binds to COX1 and keeps platelets from sticking together

Fever
inflammation
antiplatelet activity

toxicity above 300 mcg/mL

acute ingestion can cause toxicity

low to moderate pain

take with food if gastric upset occurs

aspirin

High risk of overdosing-
Avoid for 2 weeks before and after surgery
Reduce or avoid alcohol
Childproof container
Full glass of water with food
Report signs of bleeding
Don’t exceed recommended dose

Patient Teaching for Aspirin

Removing salicylate from the GI tract
Preventing Further absorption
Correcting fluid, electrolyte and acid-base disturbances
Implementing measures to enhance _____ elimination = dialysis

GI tract: pump stomach

correct fluid and electrolyte and acid base disturbances

elimination can be done through dialysis

Management of Salicylate Overdose

Very bound to plasma proteins
Tablets, chewables, suspension and drops
Maximum of 2400 mg/day
Used in osteoarthritis, rheumatoid arthritis
Used to treat pain and fever

ibuprofen

Symptoms: drowsiness, lethargy, mental confusion, paresthesias, numbness, aggressive behavior, disorientation, seizures and gastrointestinal toxicity

dialysis does not help, activated charcoal must be used and will bind with _______, it is done through an NG tube

ibuprophen,

Nonsalicylate NSAIDS Toxicity

Similar to Salicylate Overdose but usually not as extensive or dangerous

Analgesia for mild to moderate pain
Inflammation suppression
Fever reduction
Dysmenorrhea

NSAIDS (COX-2) - Indications

embolic event potential associated with _____

causes vasoconstriction and increased platelet aggregation

GI upset and renal failure as well as cardiac events are possible with this medication, as well as renal dysfunciton

COX 2 inhibitors
celecoxib

Monitor for and report gastric upset, heartburn, nausea, diarrhea, GI bleeding
Test for and treat H. pylori infection prior to long term therapy
For patients at high risk for gastric bleeding, recommend a proton pump inhibitor
Monitor I&O, watch for decreased urine output and fluid retention
Monitor for rapid rises in BUN and creatinine (important)
Recommend drug for short periods and in low doses only to minimize side effects
Monitor for MI and CVA, give low dose aspirin to prevent events

NSAIDS (COX-2) - Interventions

give aspirin a day if at risk for embolic event if they can tolerate it

give with food, water, milk if having GI issues

avoid alcohol

persistent GI irriation or problems, call their doctor

kidney: change in urine output, fluid retention, call the doctor

and S&S of MI or CVA, call doctor and ambulance

NSAIDS (COX-2) – Patient Instructions

Pregnancy Risk Category D (3rd trimester) – can cause premature closure of ductus arteriosus
Severe hepatic or renal impairment
Children < 19 year
GI bleeding, anemia
Pain from coronary bypass grafting
Allergy to sulfa, sulfonamides, or ______

NSAIDS (COX-2) - Contraindications
celecoxib

For mild to moderate pain
Great alternative to aspirin
Antipyretic drug of choice for adolescents and children with flu syndromes
Avoids risk of Reyes syndrome associated with aspirin use
doesn’t have antiplatelet effects

blocks peripheral pain by inhibition of prostaglandin synthesis

has zero anti-inflammatory properties

fewer side effects with ______

doesn’t affect coagulation: does not have cardiovascular side effects

Does not cause GI isrritation

Acetaminophen - Indications

Blocks peripheral pain by inhibition of prostaglandin synthesis
Lowers febrile body temperatures by acting on the hypothalamus
No anti-inflammatory properties (Not NSAID)
Fewer side effects
No interference with coagulation

Acetaminophen – Expected Pharmacologic Actions

Liver damage (overdose)
Hypertension (with daily use, particularly women)

Acetaminophen –Adverse Effects

Monitor for early symptoms of overdose/poisoning
Prepare to administer acetylcysteine (Mucomyst, Acetadote) orally or IV to counteract overdose and reduce liver injury
Monitor blood pressure in patients, particularly in women who take acetaminophen regularly

Acetaminophen - Interventions

Potentially lethal if overdosed
Results in hepatic toxicity
Acute hepatotoxicity can usually be reversed with acetylcysteine
Long term hepatotoxicity is likely to be permanent
Maximum daily dosage for healthy adults = 3g (some will still say 4g? FDA (2014))

Toxicity and Management of Acetaminophen Overdose

Given orally, IV or rectally
Do not administer > 3g/day to adults and children over 12 years of age
Infants and children should be given the manufacturers recommended dose based on age
Caution patients about OTC
will not prevent a heart attack or stroke

Acetaminophen - Administration

Doesn’t cause gastric irritation or bleeding
Won’t relieve inflammation
Won’t prevent heart attack or stroke
Watch OTC labels (do not exceed 3g/day)
Don’t exceed recommended dose or duration
Avoid alcoholic beverages
Report abdominal discomfort, N/V, sweating, diarrhea immediately
Check BP often (especially in women)
Watch dosages and measure carefully, especially for children

Patient Teaching: Acetaminophen

Drug allergy
Severe liver disease
Genetic disease = glucose-6-phosphate dehydrogenase deficiency
Alcoholism

Acetaminophen Contraindications

Moderate to moderately severe pain

Centrally Acting Nonopioid - Indications

What are the uricosurics?

allopurinol
febuxostat
probenecid

allopurinol

uricosurics

febuxostat

uricosurics

probenecid

uricosurics

Inhibit Xanthine oxidase (XO) from converting hypoxanthine and xanthine to uric acid
Block formation of uric acid

Allopurinol and Febuxastat

Inhibits tubular reabsorption of uric acid in kidneys
Promotes excretion of uric acid

Probenecid

Hypersensitivity syndrome (fever, rash, eosinophilia, liver and kidney dysfunction)
GI disturbances (N/V, diarrhea)
Drowsiness, headache, vertigo
Agranulocytosis (decreased white blood cells), aplastic anemia, bone marrow depression
Metallic taste in mouth ( causes people to not want to eat)
Cataracts (with drugs therapy > 3 years)

Uricosurics – Adverse Effects

Monitor for symptoms of hypersensitivity syndrome
If fever or rash develop stop medication immediately and check liver and kidney function
Monitor for worsening GI effects
For vomiting, ensure adequate hydration
Give drug after meals
Monitor patients for drowsiness or vertigo – fall risk
Monitor CBC, liver, kidney function tests and uric acid levels
Monitor for unusual taste sensations
Recommend regular eye exams

Uricosurics – Interventions

Oral or IV
Monitor uric acid levels (initially, every 1-2 weeks to establish appropriate dosage)
Obtain baseline CBC and test liver and kidney function and monitor periodically
Allow crushing tablets, mixing them with food or liquid
Administer IV using recommended dilution and infuse over 30-60 minutes
Make sure patient drinks at least 3L per day

Uricosurics – Administration

report : fever, rash, abdominal pain

3 liters of fluid or more per day

avoid driving or activities that require mental alertness until they know if med is going to cause drowsiness

if causes a headache, try OTC medicine

report bleeding, easy bruising, sore throat, aemias, bone marrow suppression

protect their eyes from sunlight bc theyre at higher risk for cataracts

need to report blurred vision and see eye doctor regularly

contraindication: hypersensitive to medicine itself

renal impairment

Uricosurics – Patient Instructions

Hypersensitivity to Allopurinol
Avoid in patients with renal impairment

Uricosurics – Contraindications

Symptomatic relief of pain and inflammation in both inflammatory and autoimmune disorders
Management of many skin disorders, allergic reactions
Delay of progression of some disorders like rheumatoid arthritis
Prevention of organ rejection
Adjunctive therapy for some cancers

Glucocorticoids - Indications

______ Inhibit synthesis of prostaglandins which decreases pain
They decrease permeability of capillaries which decreases swelling
ihibit lysosomal activity which decreases inflammation
decrease production of lymphocytes which decreases immune response

Glucoccorticoids

Suppression of adrenal function
Hyperglycemia
Myopathy
Peptic ulcer disease, GI discomfort
Infection
Fluid and electrolyte imbalances
Fat redistribution
Bone loss
Cataracts

glucocorticoids

Increase doses during stress or illness
Monitor blood glucose especially in diabetic patients
Adjust dosages of insulin and oral hypoglycemics as needed
Observe for GI bleeding
Protect GI, give med with food and recommend not using an NSAID
Observe for signs of infection
Regular eye exams

Glucocorticoids - Interventions

Orally, IV, IM, SC, topically, intranasally, inhalation
Short term – largest dose on first day and taper for 8 days
Long term – (10 or more days) take in the morning and use alternate dosing
Taper dose slowly when symptoms are controlled to establish lowest possible dose
Give supplemental doses as needed for times of stress

Glucocorticoids - Administration

Systemic fungal infection
cataracts

Glucocorticoids - Contraindications

Reduces nervousness, excitability, irritability
Does not cause sleep

sedative

Causes sleep, drowsiness

hypnotic

______ work by causing relaxation, know that it calms and relaxes the central nervous system.

Benzos

______ can cause addiction, less likely to be given routinely because it causes people to become addicted to the med

Benzos

Anxiety
Insomnia
Seizure disorders
Muscle spasm
Alcohol withdrawal (blood pressure/autonomic hyperactivity)
Preoperative relief of anxiety

benzodiazepines therapeutic uses

CNS Depression
Respiratory depression
Abuse potential

Paradoxical effects: Rebound anxiety effects, insomnia, excitation

adverse effects associated with benzodiazepines

Most of these meds are not good for elderly people because of high fall risk and the potential for the drug to build up in their system, psychosis, glaucoma, kidney dysfunction, alcohol intoxication (causes system to slow down, resp depression), pregnancy

_____ ARE NOT TO BE GIVEN LONG TERM, PRIMARILY SUPPOSE TO BE GIVEN SHORT TERM

if patient is taking a _____ and have to stop taking it, you have to taper off, you cant just stop cold turkey, they will have withdrawal

Avoid activities that require focus and attention, the meds make you groggy and less able to pay attention, they shouldn’t be driving

BENZOS

Psychosis
Acute narrow angle glaucoma
Renal (kidney) or hepatic (liver) dysfunction
Acute alcohol intoxication
Pregnancy

contraindications with benzos

Longer the use, higher the dose
the shorter acting, the more likely
occurs most often 4-5 days after discontinuation

Benzodiazepine withdrawal

Early signs:
Lack of coordination, lightheaded
Slowed or slurred speech
Other cognitive impairments (drowsy, anterograde amnesia, confusion)
Late signs:
Poor judgment
Slowed breathing
Slowed heart rate
Confusion
Lethargy

CNS depression
Benzos cause CnS depression if you take too many

if you give an IV infusion of a ______ it can cause cardiac arrest if you give it too fast, IV administration has to be given very slow

benzo

Short‑term use: anxiety, insomnia, tremors and dizziness
Long‑term use: delirium, paranoia, panic, hypertension and seizures
Reduce dose by 10-25% every 1-2 weeks over 4-16 weeks
Monitor client carefully when tapering

benzodiazepine withdrawal

Altered Mental Status
Bradycardia (Heart rate below 60)
Unable to walk or coordinate movements (ataxia)
Speech garbled or slurred
Experience hallucinations or memory loss
Decreased respirations

s/s of toxicity from benzos

Oral overdose: Drowsiness, lethargy, excessive sedation/coma, respiratory depression, reduced muscle coordination and confusion
Intravenous overdose: Life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest
General treatment measures
Oral: Gastric lavage, activated charcoal, saline cathartic, and dialysis

benzo acute toxicity/treatment

_________competes with the same receptor as benzodiazepines
Approved for benzodiazepine overdose and for reversing the effects of benzodiazepines after general anesthesia
Quick acting: 1-2 minutes, Peak 6-10 minutes
Short duration: repeated dosing needed
Dose depends on the problem: suspected overdose? Reversal of conscious sedation or Anesthesia? Look at unbound

Flumazenil

Flumazenil only works on _____

BENZOS

Sedative-hypnotic
Most widely used hypnotic
Short-term management of insomnia
Side effects: Daytime drowsiness and dizziness
Administer just before bedtime
CR is approved long term

Zolpidem [Ambien], Zolpidem Tartrate [Ambien CR
Benzo like drugs

Many take these at bedtime

Do some funky things to elderly, increased confusion (increased falls)

Most widely used hypnotic

for short term management of insomnia

CR is approved for long term

ADMIN JUST BEFORE BEDTIME, they can have daytime drowsiness or dizziness, may be groggy in the mornings, the Controlled release has two different drug reservoirs one has meds to have go to sleep and the other has stuff to help them stay asleep

Zolpidem
Zolpidem tartrate

Chronic anxiety
Gradual onset
Must be tapered
Take with food to increase drug effectiveness

______ can be used to manage chronic anxiety, is not a Benzo, don’t need to know specifically how it works

Benzos work very quickly, but ______ doesn’t work that way it takes weeks for it to start affecting your anxiety to the point that you would actually know it

______ is now for acute anxiety, the med works over a period of time

_______ needs to be tapered off

if they take it with food, it increases the effectiveness of med

Buspirone

New class of hypnotics, pyrazolopyrimidines
Short-term management of insomnia
Prolonged use does not appear to cause tolerance
Most common side effects: Headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain

zaleplon

For treatment of insomnia
No limitation on how long it can be used
Most common adverse effect: Bitter aftertaste
Other common side effects: Headache, somnolence, dizziness, and dry mouth

eszopiclone

Herbal product
Not subject to FDA regulation
Don’t combine with other CNS depressants
May increase bleeding risks with anticoagulants

melatonin

Causes tolerance and dependence
High abuse potential
Multiple drug interactions
Powerful respiratory depressants that can be fatal with overdose
Rapid onset and brief duration
CNS depression
Cardiovascular effects

barbiturates

not for home use, they’ll be given in the hospital,

______: cause tolerance and dependence, high abuse potential, many drugs interactions, powerful respiratory depressants, given rapidly and have short duration, CNS depression, not recommended for sleep aid, can cause heart attack, increased risk of fall, deprive people of REM sleep

Barbiturates

Acute Toxicity Symptoms
Respiratory depression
Coma
Pinpoint pupils
Treatment
Removal of ______ from the body (activated charcoal)
Maintenance of an adequate oxygen supply to the brain
Maintain body heat
Support blood pressure
No specific antidote

barbiturate

sedative hypnotic
onset 30 minutes
works for both difficulty falling asleep or difficulty staying asleep
may alter digoxin levels
grapefruit juice increases blood levels and sedation
may cause complex sleep behaviors –sleep walking, eating, or driving

suvorexant - sedative hypnotic (non Benzo)

Multiple seizures occur with no recovery between them.
Result: hypotension, hypoxia, brain damage, and death
True medical emergency
Basic Nursing Care

status epilepticus

what is the drug of choice for status epilepticus?

IV lorazepam

if no IV access, what drug is used for status epilepticus?

rectal diazepam or nasal midazolam

Slows down movement of electrolytes
Sodium, potassium, calcium, magnesium
Decreases the speed of nerve impulses
Cell membranes become less excitable
Increases the seizure threshold
Limits the spread of seizures to different areas
Some types enhance GABA effects

antiepileptic/convulsant medications MOA

Control or prevent seizures
Maintain a reasonable quality of life
70% are seizure free with just one medication
30% are more complex, may require several medications

goals of therapy for antiepileptics

Highly individualized medication regimen
Life-long medication management
Serum drug concentrations must be monitored
Therapeutic drug range is flexible

nursing actions for antiepileptic drugs

What is the therapeutic range for phenytoin?

10-20 mcg/ml

Adverse effects: gingival hyperplasia, acne, hirsutism, Dilantin facies, and osteoporosis
CNS effects: Sedation, blurred vision, cognitive impairment
Decreases synthesis of Vitamin D
Skin and Cardiovascular problems
Administer at slow IV rate (no faster than 50 mg/min) and ONLY with normal saline

adverse effects of phenytoin

Usually well tolerated, effective at treating seizures, and relatively inexpensive.
Half life allows for twice or even once a day dosing which encourage adherence.

advantages of phenytoin

Intravenous (IV) administration
Very irritating to veins
Slow IV directly into a large vein through a large-gauge (20-gauge or larger) venous catheter
Diluted in normal saline (NS) for IV infusion
Filter must be used
Saline flush

phenytoin administration

Inject IV form slowly
No more than 50mg/min
In older adults give 25mg/min
Therapeutic ______ level 10-20 mcg/mL
Lower if malnourished or renal failure
STRICT ADHERENCE to medication regimen
Do not abruptly d/c = withdrawal symptoms, may trigger seizures
Highly protein bound

Phenytoin nursing notes

What is the therapeutic level for carbamazepine?

4-12 mcg/ml

May need to increase dose after 2 months due to autoinduction
CNS effects (vision problems, vertigo)
Risk for fluid overload – a nursing diagnosis
Blood cell problems (leukopenia, anemia, thrombocytopenia)
Skin disorders from mild to severe

carbamazepine

What is the WBC normal range?

4500-1100

What is the platelets normal range?

150000-450000

What antiepileptic drug is associated with thrombocytopenia/blood disorders?

carbamazepine
(also valproic acid causes thrombocytopenia)

White blood cells (WBC) – 4500-11000 WBC/microliter
Complete blood cell count
Platelets – 150000-450000 platelets/microliter
Do NOT mix with other oral drug suspensions
Avoid grapefruit with ______
Sore throat, fever, easy bruising (signs of bone marrow suppression

carbamazepine

What is the therapeutic level of valproic acid?

50-100 mcg/ml

General GI problems (N/V, indigestion)
Hepatotoxicity  Hepatitis
Decreased appetite, abdominal pain, jaundice, n/v, liver function labs
Pancreatitis
Nausea, vomiting, and abdominal pain, changes in amylase levels
CNS effects from hyperammonemia
Thrombocytopenia
Bruising, bleeding, prolong the bleeding times, decrease the platelets

valproic acid

Labs to monitor
Hepatotoxicity: Liver function labs (next slide)
Pancreatitis: Changes in amylase levels (Normal: 30 to 110 units per liter (U/L))
Hyperammonemia: Normal Ammonia range: 15 to 45 µ/dL (11 to 32 µmol/L)
Thrombocytopenia: Platelets normal range: 150,000 to 450,000

Administer slowly
Dilute the IV form in at least 50ml of NS 0.9%
Do not mix with other drugs in solution

nursing notes for valproic acid

Contraindication:
Pregnancy*
Bone marrow suppression (Gabapentin)
Within 14 days of taking a MAOI (Gabapentin)

contraindications with newer antiepileptics

CNS effects
Suicidal ideation – worse with Lamotrigine (Lamictal)
Skin disorders – mild to life threatening
Multiorgan hypersensitivity reaction with Oxcarbazepine

adverse effects of all newer AEDs

Headache, dizziness, nausea
Rash  Multi-organ hypersensitivity
Fever with some or all of the following: lymphadenopathy, hepatorenal syndrome, hematologic abnormalities

oxcarbazepine specific adverse reactions

Contraindications: drug allergy
Common side effects: relatively minor CNS and GI symptoms
Adverse effects:
Aseptic meningitis: headache, fever, stiff neck, nausea, vomiting, rash, sensitivity to light
Steven-Johnson syndrome
Thrombocytopenia
Changes in seizure

side effect/adverse effects associated with lamotrigine

Adverse effects: similar CNS and GI symptoms as previous meds, increased bleeding/bruising/nosebleeds (thrombocytopenia), changes in menstrual cycle, osteoporosis/rickets

topiramate adverse effects (similar to all of the newer AEDs I think)

Loss of pleasure or interest (anhedonia)
Insomnia (or sometimes hypersomnia)
Anorexia (or sometimes hyperphagia)
Mental slowing and loss of concentration
Feelings of guilt, worthlessness, and helplessness
Thoughts of death and suicide/overt suicidal behavior
Symptoms must be present most of the day, nearly every day, for at least 2 weeks

clinical features of depression

Symptoms resolve slowly
Initial responses develop after 1 to 3 weeks
Maximal responses may not be seen for 12 weeks
Failure when taken 1 month without success

considerations for all antidepressants

May increase suicidal tendencies during early treatment
Patients should be observed closely for the following:
Suicidality
Worsening mood
Changes in behavior
Precautions
Prescriptions should be written for the smallest number of doses consistent with good patient management
Dosing of inpatients should be directly observed

considerations for all antidepressants

Begins 2 to 72 hours after treatment
Altered mental status (agitation, confusion, disorientation, anxiety, hallucinations, and poor concentration)
Incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever
Deaths have occurred
resolves spontaneously after discontinuing the drug
Risk increased by concurrent use of MAOIs and other drugs

serotonin syndrome (associated with SSRIs)

Early symptoms:
Nausea, diaphoresis, tremor, nervousness, *Suicidal ideation (SI)

Later symptoms:
Sexual dysfunction, weight fluctuation, *Serotonin Syndrome, GI bleed, hyponatremia, bruxism, orthostatichypotension

SSRI adverse effects

monitor platelets
elderly or renal impaired may need lower dose
can take 1-3 weeks to work
sodium labs esp if taking diuretic
may need to d/c in pregnancy or 3rd trimester
do not d/c abruptly - withdrawal symptoms

nursing notes for SSRIs

Caution:
Serotonin Syndrome* (SSRIs, TCAs)Hx of bipolar disorder, mania, seizure disorder, recent MI, or interstitial lung disease

Contraindication:
MAOIs within 14 days Renal OR Hepatic impairmentEspecially with substantial alcohol use/abuse

SNRI caution/contraindication

Fatigue/drowsiness or paradoxical effects (insomnia, anxiety, HTN, tachycardia)
Decreased appetite or weight loss, nausea
Sexual dysfunction
Hyponatremia (duloxetine)
Respiratory Issues (venlafaxine)

SNRI adverse effects

Serotonin Syndrome Hepatotoxicity
Seizures Suicidal ideation

life threatening SNRI adverse effects

Do not abruptly d/c – withdrawal symptoms
Take in the morning if interrupts sleep
Take with food if it causes upset stomach
Avoid MAOIs
Obtain baseline sodium levels for older adult clients taking diuretics, monitor periodically- normal range is 135 and 145 milliequivalents per liter (mEq/L)

SNRIs

MAOIs within 14 days Renal OR Hepatic impairmentEspecially with substantial alcohol use/abuse

contraindications for SNRIs

Fatigue/drowsiness or paradoxical effects (insomnia, anxiety, HTN, tachycardia)
Decreased appetite or weight loss, nausea
Sexual dysfunction
Hyponatremia (duloxetine)
Respiratory Issues (venlafaxine)

SNRI adverse effects

original first generation antidepressants
How it Works:
Blocks reuptake of norepinephrine & serotonin
Corrects imbalance

Used For:
Treatment resistant Depression
Painful neuropathy

TCA antidepressants

Contraindication
Use of MAOIs
Seizures
Recent MI

contraindications for TCAs

Constipation
Urinary retention
Blurred vision, photophobia
Dry mouth
Tachycardia
Feel hot, dry
Confusion

Cardiovascular effects
Cardiac conduction problems (dysrhythmias)
Hypotension

S/S of Toxicity/Overdose
Cardiac dysrhythmias, mental confusion, agitation followed byseizures, coma, and possible death

Adverse effects with TCAs

Therapeutic effects within 2-3 weeks
Full therapeutic effects can take 2-3 months
How to manage side effects (anticholinergic)
Assess for suicidal ideation, weight gain, and orthostatic hypotension

Nurse notes for TCAs

How it Works:
Inhibits MAO enzyme
Enzyme no longer can metabolize (many) neurotransmitters

Method of action for MAOIs

Caution
Large amounts of caffeine, cough/cold meds, diet pills (stimulants)
Diabetes and seizure disorders
Moderate levels of ______ foods: Yogurt, bouillon, non aged cheese (cottage cheese, mozzarella), bananas, red wine, fava beans

Tyramine
MAOIs interact with tyramine

Contraindication
Heart failure, cardiovascular and cerebral vascular disease, and severe renal insufficiency
MANY medications and OTC (ex. Meperidine)
High levels of tyramine rich foods: Aged cheese (blue, swiss, cheddar), smoked/pickled/aged meats, yeasts, etc.

Contraindications with MAOIs, also tyramine

CNS stimulation
Blood pressure changes
Orthostatic HYPOtension
Or HYPERtensive crisis

Hypertensive Crisis
Severe hypertension, severe headache, nausea, increased apical heart rate, chest pain
Most common in “Non-selective” ______

Serotonin Syndrome

MAOIs adverse effects

Goal: Protect brain and heart
Game Plan: Eliminate the ______
How: Phentolamine (Regitine) or nifedipine SL (Procardia)
Monitor cardiac function
Continuous monitoring not just an EKG
Monitor and support respiratory function

MAOI

d/c 14 days before anesthetics and other antidepressants

can take several weeks before therapeutic effects are seen
educate patient about tyramine rich foods andinteractions with many medicaitons

MAOI nursing notes

Reduce pain sensation at level of peripheral nerves

local anesthetics

Block sodium channels and conduction

local anesthetics

Block sodium channels and conduction

local anesthetics

Topical anesthetic
Indications: postherpetic neuralgia/before IV start
Left in place no longer than 12 hours
Minimal adverse effects

Local/Regional Anesthetic
Duration 60-75 minutes
Max dose 4 mg/kg or 7 mg/kg with epinephrine
Toxic IV dose: 250 mg

xylocaine

Advantages
Effective alternative to GA
Avoids polypharmacy
Patient can remain awake
Early drink/feed

     Disadvantages Limited scope Higher failure rate Time constraints Anticoagulants Risk of neural injury

local anesthetics

_____ is often administered with the local anesthetic (lidocaine with ______ for example)
_____ also decreases local blood loss

Epinephrine

Damage to the nerve
Persistent numbness, weakness, or pain
Rare
Risk of systemic toxicity
Other complications: infection, swelling, or bruising (hematoma) at the injection site.
Spinal administration only: “spinal headache

Risks for regional anesthetics

blocks a nerve or small bundle of nerves

Peripheral regional

Blocks large area- causes loss of sensation of pain and paralysis to the area.
Not as risky as general- doesn’t cause loss of consciousness.

Regional Central

Doesn’t cause complete loss of consciousness
Does normally cause respiratory arrest
Increasing due to more office/outpatient surgery centers
Allows patient to relax; reduces anxiety- airway intact; can follow commands, more rapid recovery than general anesthesis.
Most commonly used= short acting benzodiazepine- midazolam (versed) usually given with short acting opoid (fentanyl or morphine

moderate Sedation or procedural sedation

doesn’t do anything for pain, just used for sedation

if a patient routinely dirnks alcohol, you might need a higher dose

have to be certified to monitor patient in conscious sedation

doesn’t do anything for pain, just used for sedation

if a patient routinely dirnks alcohol, you might need a higher dose

have to be certified to monitor patient in conscious sedation

Midazolam (Versed)

Apnea, respiratory depression, post-op respiratory depression
Tends to reduce BP and peripheral vascular resistance more than Diazepam

Adverse reactions associated with midazolam

 Aids intubation
 Surgery of long duration
 Reduces maintenance dose of anesthetics agents

Muscle relaxants

Prevent nerve transmission in skeletal and smooth muscle leading to paralysis
In conjunction with general anesthesia- diaphragm paralysis & intercostal muscles
High alert drugs- sound alike drugs= restricted access to these drugs

Neuromuscular blocking drugs

Reversible, unconscious state
Physical assessment findings: amnesia, analgesia, depression of reflexes, muscle relaxation, person is unconscious
_______ usually uses a combination of IV drugs and inhaled gasses

General anesthesia

Given IV

Often inhaled anesthetics used as well
Adjunct drugs are used

Parenteral anesthetics

Advantages
No absolute contra-indication
Quick to establish
Never fails to work

Disadvantages
Poly-pharmacy
Effects many systems
Post operative N/V

General Antethesia

Extubate once awake
Check of gag reflex
Always have suctioning equipment available

Nursing notes for general anesthesia

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